Amerlcan PollsLlc Medlcal AssoclaLlon

Membersh|p App||cat|on
Amer|can no||st|c Med|ca| Assoc|at|on
www.hollsLlcmedlclne.org l hone: 216-292-6644
27629 Chagrln 8lvd, SulLe #206 l Woodmere, CP 44122

_ Choose our Membersh|p Category

. new Member . 8enewlng Member ?ears of Lxperlence _____ uaLe _______________

Category Annua| kate !"#$% #'$ ())%*)%+(#$ +",*%-(#+*" ,*% .*/% -$-0$% 1(#$2*%.
. hyslclan $333 Llcense #, SLaLe ____________________________ LxplraLlon: __________________
. llrsL-?ear hyslclan* $130 Llcense #, SLaLe ____________________________ LxplraLlon: __________________
. Llcensed racLlLloner $183 Lxplaln ________________________________________________________________
. CerLlfled racLlLloner (non-llcensed) $130 CredenLlals/cerLlflcaLes ___________________________________________________
. lnLern / 8esldenL $30 8esldency rogram ______________________________________________________
(one-Llme fee for Lhe duraLlon of resldency) CompleLlon uaLe ________________________________________________________

. SLudenL / Medlcal SLudenL $30 SLudenL lu#: _____________ lnsLlLuLlon _______________ CraduaLlon uaLe ________
(one-Llme fee unLll graduaLlon)
. 8eLlred / ulsabled $130
. lrlend / SupporLer $100

SLudenLs recelve a $10 dlscounL lf s/he ls a member of Lhese organlzaLlons: AMSA ! nMSA ! SCMA !

Members of Lhe followlng organlzaLlons recelve a $30 dlscounL: AALM ! AAn ! ACAM ! APnA ! lClM ! llM !

Please note that only one organization discount applies.

lease aLLach any coupons: $_____ Lxp. uaLe ____uescrlbe_________________________________________




_ Comp|ete our ub||c Informat|on (Ma|n L|st|ng)

name ________________________________________________________uegree(s)__________________________________
CrganlzaLlon ____________________________________________ 1lLle____________________________________________
Address ________________________________________________________________________________________________
ClLy ________________________________ SLaLe ________ Zlp _____________ CounLry ______________________________
rlmary phone ________________________________ Work ! Cell ! Pome ! lax __________________________________
Lmall _________________________________________________ WebslLe _________________________________________
3/%%$"# )'.4+1+("4 ("5 )%(1#+#+*"$%4 *"6.7 lease do NC1 lnclude me ln APMA's Cnllne ubllc 8eferral LlsLlng. CpL CuL !

APMA ls a green organlzaLlon and uses elecLronlc flles Lo save paper and space. Powever, lf you'd prefer Lo recelve
lnformaLlon by mall only, please check here: !
* llrsL-?ear hyslclan ls for one year only and ls avallable only Lo Lhose who have [usL compleLed a resldency program.
Ma|| or fax th|s form (phys|c|ans and pract|t|oners must a|so |nc|ude a s|gned copy of the Lth|ca| Gu|de||nes)
to AnMA, 27629 Chagr|n 8ou|evard, Su|te 206, Woodmere, Ch|o 44122.
hone (216) 292-6644, Iax (216) 292-6688

_ hys|c|ans]ract|t|oners Cn|y: Areas of Spec|a|ty
!"## %&'&() *#%+,-



__AcupuncLure
__AddlcLlon
__Alexander 1echnlque
__Allergy
__AnesLheslology
__AnLhroposophlc Medlclne
__AromaLherapy
__ArL 1herapy
__ArLhrlLls
__AurlculoLherapy
__Ayurveda
__8lofeedback
__8lo-ldenLlcal P81
__8raln LongevlLy
__8reaLhwork
__Cardlology
__Cardlovascular ulsease
__ChelaLlon 1herapy
__ChlropracLlc
__Cllnlcal Lcology
__Coachlng
__CognlLlve 1herapy
__Colon PydroLherapy
__CranloSacral 1herapy
__uenLlsLry
__uermaLology
__ulabeLes
__ureamwork 1herapy
__Ll1
__LMu8
__Lmergency Medlclne
__Lndocrlnology
__Lnergy Medlclne
__LnvlronmenLal Medlclne
__Lssence 1heraples
__lamlly racLlce
__lamlly 1herapy
__leng Shul
__llLness /Lxerclse
__llower 8emedles
__luncLlonal Medlclne
__CasLroenLerology
__Ceneral racLlce
__CerlaLrlcs
__Culded lmagery
__Cynecology
__Peallng 1ouch
__PealLhy Aglng
__Perbal Medlclne
__PomeopaLhy
__Pyperbarlc Cxygen
__Pypnosls/PypnoLherapy
__lmmunology
__lnLegraLed Medlclne
__lnLernal Medlclne
__lrldology
__!ln Shln !yuLsu
__Massage 1herapy
__Medlcal lnLulLlon
__MedlLaLlon
__Men's PealLh
__MeLabollc Medlclne
__Mldwlfery
__Mlnd/8ody Medlclne
__MovemenL 1herapy
__Muslc 1herapy
__naLuropaLhy
__neurofeedback
__neurology
__nuLrlLlon
__CbsLeLrlcs
__Cncology
__CphLhalmology
__CrLhomolecular Medlclne
__CrLhopedlc Surgery
__CsLeopaLhlc/ManlpulaLlon
__CLolaryngology
__aln ManagemenL
__aLhology
__edlaLrlcs
__harmacology
__hyslcal Lxerclse
__hyslcal 1herapy
__lasLlc Surgery
__odlaLry
__olarlLy 1herapy
__revenLlve Medlclne
__roloLherapy
__sychlaLry
__sychosomaLlc Medlclne
__sychoLherapy
__ubllc PealLh
__ulmonary ulseases
__Cl Cong
__8adlology
__8eflexology
__8ehablllLaLlon 1herapy
__8elkl
__8heumaLology
__8esearch
__Sex 1herapy
__SplrlLual ALLunemenL
__SporLs Medlclne
__SLress ManagemenL
__SubsLance Abuse
__SupplemenLs
__Surgery
__1al Chl
__1herapeuLlc 1ouch
__urology
__WelghL ManagemenL
__Wellness 1ralnlng
__Women's PealLh
__?easL Syndrome
__?oga















NC1L: AddlLlonal caLegorles may be selecLed for a fee: $23/caLegory for docLors and llcensed pracLlLloners and $30/caLegory for
cerLlfled pracLlLloners. SelecL only caLegorles LhaL you use ln your pracLlce and ln whlch you are professlonally Lralned and/or llcensed.

hys|c|ans: LlmlL 3 L|censed ract|t|oners: LlmlL 3 Cert|f|ed ract|t|oners: LlmlL 1 (non-llcensed)
Amerlcan PollsLlc Medlcal AssoclaLlon
!"#$"%&'() +)),(-./(01
+#"%(-.1 20,(&/(- !"3(-., +&&0-(./(01
www.hollsLlcmedlclne.org l hone: 216-292-6644
27629 Chagrln 8lvd, SulLe #206 l Woodmere, CP 44122

APMA racLlLloner LLhlcal Culdellnes
!"#$%&'&()% ()+ ,-('.&.&/)0-% /)1$2
34536% 7&%%&/)8 401,&)9 .-()%:/-7 #0(1.#'(-0 ./ ( 7/-0 #/1&%.&' 7/+01


1he Amerlcan PollsLlc Medlcal AssoclaLlon (herelnafLer APMA") encourages hlgh sLandards of professlonallsm and proflclency of lLs
members. APMA members have dlverse Lralnlng and credenLlals, and Lhe servlces Lhey perform are mulLl-faceLed and ofLen complex. Whlle
sLaLe medlcal boards have llcensure for physlclans and many healLhcare provlders, some sLaLes do noL have speclflc educaLlonal and Lralnlng
sLandards ln Lhe heallng arLs. 1herefore, Lhe APMA encourages all pracLlLloners Lo seek ouL Lralnlng and credenLlals from lndlvlduals and
schools LhaL are recognlzed and respecLed ln Lhelr fleld of speclalLy. ln addlLlon, all APMA members are encouraged Lo expand Lhelr
knowledge of varlous heallng modallLles. 1o LhaL exLenL we suggesL LhaL conLlnulng medlcal/educaLlon unlLs ln supporL of hollsLlc healLh
pracLlces be acqulred no less Lhan bl-annually.

1o promoLe hlgh eLhlcal sLandards and provlde guldance and clarlLy, Lhe APMA encourages all lLs docLor and pracLlLloner members Lo
embrace Lhe prlnclples and values ouLllned below.

4%(1-(),"& 05 60137-/

1. A member shall 7(&).(&) ()+ (+;()'0 .#0 <)/=10+90 /: #/1&%.&' ,-('.&'0 and %#(11 '/).-&>?.0 ./ .#0 9-/=.# ()+ +0;01/,70). /: .#0
#0(1&)9 (-.%. 1hls lncludes:
uLLlng hollsLlc mlsslon above personal galn.
uemonsLraLlng a conslsLenL paLLern of reasonable care and compeLence wlLhln Lhe area of pracLlce.
Adherlng Lo Lhe splrlL, as well as Lhe leLLer of Lhe law ln Lhe conducL of professlonal acLlvlLles.
SLrlvlng Lo lmprove professlonal knowledge and sklll, lncludlng parLlclpaLlon ln educaLlonal programs and
personal developmenL, so LhaL Lhelr performance wlll beLLer serve oLhers.
upholdlng human rlghLs ln all endeavors.

2. A member shall %0-;0 #&%@#0- '1&0).% '/7,(%%&/)(.01$A '/7,0.0).1$A &) ( ,-/:0%%&/)(1 ()+ ?),-0B?+&'0+ 7())0-A =&.# +&9)&.$ ()+ -0%,0'..
1hls lncludes:
rovldlng servlces Lo Lhe besL of hls/her ablllLy and wlLh lnformed consenL LhroughouL.
Pelplng Lhe cllenL undersLand Lhe scope of servlces, approach Lo be used, and fee sLrucLures.
uecllnlng Lo make commlLmenLs LhaL cannoL llkely be fulfllled or Lo provlde servlces for whlch one does noL
have Lhe approprlaLe knowledge, Lralnlng, and experlence.

3. A member shall -0:-(&) :-/7 %0C?(1 &).&7('$ wlLh hls/her cllenLs and shall -07(&) &)+0,0)+0). /: ()$ (::&1&(.&/)% .#(. '/?1+ '/7,-/7&%0
#&%@#0- B?+970). or resulL ln Lhe appearance of compromlse or lmproprleLy. A member's duLy ls solely Lo Lhe cllenL.

4. A member shall 7(&).(&) ( #&9# 10;01 /: .-?.# ()+ '()+/-. 1hls lncludes:
noL lnLenLlonally or recklessly mlsleadlng exlsLlng or prospecLlve cllenLs abouL resulLs LhaL can be anLlclpaLed .
8efralnlng from offerlng soluLlons or maklng recommendaLlons LhaL are unreallsLlc or lmpracLlcal.
Cpenly sharlng lnformaLlon concernlng Lhe fee for servlces and expecLed Llmellnes.

3. A member wlll #/1+ (% '/):&+0).&(1 (11 '1&0). &):/-7(.&/)A refralnlng from releaslng any lnformaLlon Lo anyone wlLhouL auLhorlzaLlon
from Lhe cllenL, excepL as provlded for by law. CllenLs wlll be allowed reasonable access Lo a member's wrlLLen record abouL Lhe cllenL.

6. A member shall />%0-;0 ()+ ,-('.&'0 (,,-/,-&(.0 0.#&'(1 7/)0.(-$ ,/1&'$8
LlmlLlng Lhe source of cllnlcal lncome Lo medlcal servlces acLually rendered by Lhe pracLlLloner.
MoneLary fee should be commensuraLe wlLh Lhe servlces rendered.
1he pracLlLloner should nelLher pay nor recelve a commlsslon for referral of paLlenLs.
urugs, remedles or appllances may be dlspensed or supplled by Lhe pracLlLloner provlded lL ls clearly ln Lhe besL lnLeresLs of Lhe
paLlenL. 1he paLlenL musL be glven addlLlonal resources, daLa or lnformaLlon for Lhe lLems lf requesLed.



Ma|| or fax th|s form (phys|c|ans and pract|t|oners must a|so |nc|ude a s|gned copy of the Lth|ca| Gu|de||nes)
to AnMA, 27629 Chagr|n 8ou|evard, Su|te 206, Woodmere, Ch|o 44122.
hone (216) 292-6644, Iax (216) 292-6688
7. A member shall !"#$%& (#) *+(),-*(. /+& &*,+*(. $0 (#) #$%*1(*2 "-$0)11*$+. 1hls lncludes:
8efralnlng from referrlng a cllenL Lo a colleague ln exchange for moneLary conslderaLlon from LhaL colleague or ln any way sharlng
ln any fee recelved by such colleague.
8elng forLhcomlng and LruLhful abouL hls/her credenLlals, llcensures, accredlLaLlon and/or capablllLles, recognlzlng
boundarles of compeLence, worklng cooperaLlvely wlLh oLher pracLlLloners ln Lhe besL lnLeresL of Lhe cllenL.
noL glvlng Lhe lmpresslon LhaL 3453 membershlp besLows any credenLlals or guaranLees mlnlmum
quallflcaLlons.
Subscrlblng, and represenLlng LhaL he/she subscrlbes, Lo Lhls Code of LLhlcs.

1o malnLaln Lhe lnLegrlLy of Lhe APMA we requesL LhaL all members supporL Lhe 1en rlnclples of PollsLlc Medlclne".

1. Cpt|ma| hea|th ls Lhe prlmary goal of hollsLlc medlcal pracLlce. lL ls Lhe consclous pursulL of Lhe hlghesL level of funcLlonlng and
balance of Lhe physlcal, envlronmenLal, menLal, emoLlonal, soclal and splrlLual aspecLs of human experlence, resulLlng ln a dynamlc
sLaLe of belng fully allve. 1hls creaLes a condlLlon of well-belng regardless of Lhe presence or absence of dlsease.

2. 1he nea||ng ower of Love. PollsLlc healLhcare pracLlLloners sLrlve Lo meeL Lhe paLlenL wlLh grace, klndness, accepLance, and
splrlL wlLhouL condlLlon, as love ls llfe's mosL powerful healer.

3. Who|e person. PollsLlc healLhcare pracLlLloners vlew people as Lhe unlLy of body, mlnd, splrlL and Lhe sysLems ln whlch Lhey llve.

4. revent|on and 1reatment. PollsLlc healLhcare pracLlLloners promoLe healLh, prevenL lllness and help ralse awareness of dls-
ease ln our llves raLher Lhan merely managlng sympLoms. A hollsLlc approach relleves sympLoms, modlfles conLrlbuLlng facLors, and
enhances Lhe paLlenL's llfe sysLem Lo opLlmlze fuLure well-belng.

3. Innate nea||ng ower. All people have lnnaLe powers of heallng ln Lhelr bodles, mlnds and splrlLs. PollsLlc healLhcare
pracLlLloners evoke and help paLlenLs uLlllze Lhese powers Lo affecL Lhe heallng process.

6. Integrat|on of nea||ng Systems. PollsLlc healLhcare pracLlLloners embrace a llfeLlme of learnlng abouL all safe and effecLlve
opLlons ln dlagnosls and LreaLmenL. 1hese opLlons come from a varleLy of LradlLlons, and are selecLed ln order Lo besL meeL Lhe
unlque needs of Lhe paLlenL. 1he realm of cholces may lnclude llfesLyle modlflcaLlon and complemenLary approaches as well as
convenLlonal drugs and surgery.

7. ke|at|onsh|p-centered care. 1he ldeal pracLlLloner-paLlenL relaLlonshlp ls a parLnershlp LhaL encourages paLlenL auLonomy, and
values Lhe needs and lnslghLs of boLh parLles. 1he quallLy of Lhls relaLlonshlp ls an essenLlal conLrlbuLor Lo Lhe heallng process.

8. Ind|v|dua||ty. PollsLlc healLhcare pracLlLloners focus paLlenL care on Lhe unlque needs and naLure of Lhe person who has an
lllness raLher Lhan Lhe lllness LhaL has Lhe person.

9. 1each|ng by Lxamp|e. PollsLlc healLhcare pracLlLloners conLlnually work Loward Lhe personal lncorporaLlon of Lhe prlnclples of
hollsLlc healLh, whlch Lhen profoundly lnfluence Lhe quallLy of Lhe heallng relaLlonshlp.

10. Learn|ng opportun|t|es. All llfe experlences--lncludlng blrLh, [oy, sufferlng and Lhe dylng process--are profound learnlng
opporLunlLles for boLh paLlenLs and healLhcare pracLlLloners.

C||ent's k|ghts

lf a cllenL so deslres, APMA members wlll encourage Lhe cllenL Lo seek lnformaLlon, educaLlon and poLenLlal LreaLmenL from oLher modallLles
and pracLlLloners. lf a cllenL LermlnaLes an APMA pracLlLloner's servlces, Lhe cllenL has a rlghL Lo coordlnaLed Lransfer of servlces Lo anoLher
pracLlLloner. A cllenL has a rlghL Lo refuse servlces aL any Llme, recognlzlng LhaL Lhere may be legal ramlflcaLlons Lo Lhe paLlenL for Lhelr
declslon. A cllenL has a rlghL Lo be free of physlcal, verbal or sexual abuse. A cllenL has a rlghL Lo know Lhe expecLed duraLlon of LreaLmenL
and may asserL any rlghL wlLhouL reLallaLlon.

unless llcensed Lo do so, APMA members wlll noL provlde a medlcal dlagnosls or recommend dlsconLlnuance of medlcally prescrlbed
LreaLmenLs. unless llcensed Lo do so, APMA pracLlLloners wlll noL represenL Lhelr servlces as any form of healLhcare or psychoLherapy and by
law, may make no healLh beneflL clalms Lo cllenLs. Servlces may be moLlvaLlonal, coachlng, educaLlonal, or lnsplraLlonal ln naLure, and a
cllenL may be gulded Lo uLlllze hls/her own lnnaLe splrlLual resources ln order Lo aLLaln poslLlve beneflLs.

lf cllenLs have a complalnL abouL APMA members' servlces or behavlor LhaL Lhe member cannoL resolve personally, Lhe cllenL may conLacL
APMA Lo seek redress.

nC1L: 1he APMA wlll noL be held legally responslble for Lhe pracLlce and LreaLmenL cholces of member pracLlLloners.





Amerlcan PollsLlc Medlcal AssoclaLlon
!"#$"%&'() +)),(-./(01
+#"%(-.1 20,(&/(- !"3(-., +&&0-(./(01
www.hollsLlcmedlclne.org l hone: 216-292-6644
27629 Chagrln 8lvd, SulLe #206 l Woodmere, CP 44122


4 !"/'03 05 6.7#"1/

1erms and CondlLlons:

l acknowledge and accepL Lhe Amerlcan PollsLlc Medlcal AssoclaLlon eLhlcal guldellnes and volce supporL
for Lhe 10 rlnclples" as a prerequlslLe Lo my accepLance of membershlp.

8y paylng Lhe APMA, l auLhorlze APMA Lo charge my accounL for Lhe LoLal amounL due as speclfled
below. unless dlrecLed oLherwlse ln wrlLlng below, aL Lhe end of Lhe lnlLlal Lerm, Lhls AgreemenL shall
auLomaLlcally renew for successlve one-year perlods unless LermlnaLed by elLher parLy.

! l agree Lo Lhese 1erms and CondlLlons
! l wlll be bllled annually unless oLherwlse speclfled here: 8(,, #" ! MonLhly ! CuarLerly


1oLal AmounL uue: ____________

Member SlgnaLure _____________________________________________ uaLe ____________________

Check Lnclosed (Make payable Lo APMA) ! Check # _____________________________________

1ype of CredlL Card: vlsa ! MasLerCard ! Amerlcan Lxpress !

CredlL Card # ____________________________________ Lxp. ___________ SecurlLy Code ___________

rlnL name as lL appears on CC ____________________________________________________________

8llllng address: Same as maln llsLlng !

CLher _________________________________________________________________________________



x